Diseases of the EAC - Alexorlalexorl.edu.eg/alexorlfiles/alexorl2013-presentations/018001.pdf · Roland 2 Excess cerumen Adults 3Adults 3-10%10 % 5 di N50005 studies N=5000 Children

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Diseases of the EACDiseases of the EACPETER ROLAND, MDPETER ROLAND, MD

BRANDON ISAACSON, MDBRANDON ISAACSON, MD

UT SOUTHWESTERNUT SOUTHWESTERNUT SOUTHWESTERNUT SOUTHWESTERN

DALLAS TXDALLAS TX

DisclosuresDisclosures

Consultant to Alcon LabsConsultant to Alcon Labs RolandRoland Consultant to Alcon Labs Consultant to Alcon Labs –– RolandRoland

Course Instructor Medtronic Midas Course Instructor Medtronic Midas Rex Institute Rex Institute -- IsaacsonIsaacson

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Excess cerumenExcess cerumen

Adults 3Adults 3 10 %10 % 5 di N 50005 di N 5000 Adults 3Adults 3--10 % 10 % 5 studies N=50005 studies N=5000

Children 10% Children 10% 2 studies N=5732 studies N=573

Geriatric 34% Geriatric 34% 11 studies N=104studies N=104

Institutionalized 22Institutionalized 22-- 36% 36% 4 studies N=5754 studies N=575

Cerumen removalCerumen removal

CerumenolyticsCerumenolytics CerumenolyticsCerumenolytics Peroxide basedPeroxide based

Cerumenex®Cerumenex®

NaHCO3NaHCO3

OtherOther

MechanicalMechanical MechanicalMechanical

IrrigationIrrigation SyringeSyringe

Water picWater pic

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Ear candlesEar candles

Ear candles -- Sealy 1996Ear candles -- Sealy 1996

No neg pressureNo neg pressure No neg pressureNo neg pressure

Burnt paraffinBurnt paraffin

Injuries Injuries (n=122)(n=122):: 13 burns13 burns

7 paraffin occlusions7 paraffin occlusions

2 TM f2 TM f 2 TM perfs2 TM perfs

3 otitis externa3 otitis externa

6 CHL6 CHL

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Cerumen management clinical practice guidelineCerumen management clinical practice guideline Why?Why? Why?Why?

Strong recommendationsStrong recommendationsRx if 1) symptomatic 2) prevents a Rx if 1) symptomatic 2) prevents a

needed examneeded exam

RecommendationRecommendationAssess for modifying factorsAssess for modifying factors

Assess HA pts regularlyAssess HA pts regularly

Cerumen management clinical practice guidelineCerumen management clinical practice guideline OptionOption OptionOptionMay observe nonMay observe non--impacted cerumenimpacted cerumen

May use cerumenolytics, irrigation, or May use cerumenolytics, irrigation, or manual removalmanual removal

Carefully assess those who may not be Carefully assess those who may not be able to express symptomsable to express symptoms

Council pts on preventionCouncil pts on prevention

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FurunculosisFurunculosis

Lateral 1/3Lateral 1/3 Lateral 1/3Lateral 1/3

Staph aureusStaph aureus

Systemic antibiotics with Systemic antibiotics with good gram + coveragegood gram + coverage Cephalosprin, clinda.,Cephalosprin, clinda.,

I&DI&D I&DI&D

External OtitisExternal Otitis

Inflammation of the EACInflammation of the EAC Inflammation of the EACInflammation of the EACAllergicAllergicIrritativeIrritativeBacterialBacterialFungalFungalViralViralViralViralPrimary DermatitisPrimary Dermatitis

Acute or ChronicAcute or Chronic

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Fungal External OtitisFungal External Otitis

Uncommon as aUncommon as a Uncommon as a Uncommon as a primary disease. primary disease. Fungal organisms may Fungal organisms may grow on desquamated grow on desquamated epithelium or cerumen epithelium or cerumen as simple saprophytesas simple saprophytes

True fungal otitis isTrue fungal otitis isTrue fungal otitis is True fungal otitis is almost always either almost always either Aspergillus or Candida Aspergillus or Candida SpeciesSpecies

Treatment of Fungal OtitisTreatment of Fungal Otitis

Mechanical debridementMechanical debridement Mechanical debridementMechanical debridement

Usually responds to reUsually responds to re--acidification acidification &/or the use of topical anti&/or the use of topical anti--septics septics (Gentian violet, mercurochrome, )(Gentian violet, mercurochrome, )

Only rarely will antifungal antibiotics Only rarely will antifungal antibiotics y y gy y gbe requiredbe required

Lucente et al: The External Ear

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Acute Bacterial Otitis ExternaAcute Bacterial Otitis Externa

AOE; PathognesisAOE; Pathognesis

Temp and humidityTemp and humidity Temp and humidityTemp and humidity

SeasonalSeasonal

pHpH

DermatitisDermatitis

TT TraumaTrauma

Fabricant et al. Arch Otorhinolaryngol: 201-9, 1949.

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History1,2

• PAIN

Diagnosis of Bacterial Diagnosis of Bacterial Acute Otitis ExternaAcute Otitis Externa

PAIN• Itching• Hearing loss

Physical examination• Swollen external auditory canal1

• Erythema (variable)2

• Watery, scant exudate2

• Tenderness/PAIN2

1. Marple BF, et al. In: Roland PS, et al, eds. Hearing Loss. 1997:133-154.2. Roland PS. Curr Infect Dis Rep. 2000;2:160-167.

Photo courtesy of Michael Hawke, MD.

Organisms (%) Recovered During a Series of Clinical Trials

Microbiology of Acute Otitis Externa

Gram-positives

45.3%45.3% Gram-negatives

52.9%52.9%

Gram-positivesStaphylococcus sp 27.4%Coryneforms 12.1%

Streptococcus + Enterococcus 3.9%

Bacillus + P ib ill 1 5%

Gram-negativesPseudomonas

aeruginosa 37.7%Enterobacteriaceae +

Vibrionaceae 8.5%

Nonfermentative

1. Roland P, Stroman D. Laryngoscope. 2002;112:1166-1177.

52.9%52.9%

Fungi and Yeast1.7%

Paenibacillus 1.5%

Micrococcus 0.24%

Actinomycetes 0.14%

Gram-negatives 3.9%

Other Pseudomonads 2.3%

Other Gram-negatives 0.45%

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AOE: TreatmentAOE: Treatment

Removal of debrisRemoval of debris Removal of debris Removal of debris

ReRe--acidification acidification

Assure delivery (remove debris or an Assure delivery (remove debris or an otowick)otowick)

AppropriateAppropriate topicaltopical antimicrobialantimicrobial Appropriate Appropriate topicaltopical antimicrobialantimicrobial

Appropriate pain managementAppropriate pain management

Systemic antibiotics are rarely requiredSystemic antibiotics are rarely required

AdvantagesAdvantages

DDelivery of high concentration (0 3%)elivery of high concentration (0 3%)DDelivery of high concentration (0.3%)elivery of high concentration (0.3%)33--5 GTTS dose is only 905 GTTS dose is only 90g g -- 150mcg 150mcg

but at a concentration of but at a concentration of 3000mcg/ml3000mcg/mlwhich exceeds the MIC of any known which exceeds the MIC of any known relevant pathogen.relevant pathogen.

MMinimal systemic effectinimal systemic effect

LLow costow cost

Alter local microAlter local micro--environmentenvironment

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DisadvantagesDisadvantages

Local discomfortLocal discomfort Local discomfortLocal discomfort pHpH

alcoholalcohol

temperaturetemperature

Require direct contactRequire direct contact

Topical sensitizationTopical sensitizationTopical sensitizationTopical sensitization

Alter microAlter micro--environment environment

Minimal systemic effectMinimal systemic effect

Practical irrelevance of Practical irrelevance of ““MICMIC””MICMIC

therefore,

li i l i i i i i lli i l i i i i i lclinical sensitivities are meaninglessclinical sensitivities are meaningless&&

changing topical antibiotics is irrationalchanging topical antibiotics is irrational

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HypersensitivityHypersensitivity

WARNING:WARNING: THETHE WARNING:WARNING: THE THE MANIFESTATION OF MANIFESTATION OF SENSITIZATION TO SENSITIZATION TO

NEOMYCIN IS NEOMYCIN IS USUALLY A USUALLY A LOW LOW

GRADEGRADE REDDENING REDDENING WITH SWELLING, DRY WITH SWELLING, DRY

SCALING AND SCALING AND ITCHING; ITCHING; IT MAY IT MAY

SIMPLY MANIFEST AS SIMPLY MANIFEST AS FAILURE TOFAILURE TO HEALHEAL

Rosenfeld et al OTO-HNS May 2006

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Strong RecommendationStrong Recommendation

M t f AOE h ld i l dM t f AOE h ld i l dManagement of AOE should include Management of AOE should include assessment of pain and a assessment of pain and a

recommendation for analgesic recommendation for analgesic treatment based on the severity of treatment based on the severity of

painpain

RecommendationsRecommendations

1) Distinguish diffuse AOE from 1) Distinguish diffuse AOE from other causesother causes

2) Assess the patient for factors that 2) Assess the patient for factors that modify treatmentmodify treatment

Nonintact TM TT diabetesNonintact TM TT diabetesNonintact TM, TT, diabetes, Nonintact TM, TT, diabetes, immunocomprimised state, prior immunocomprimised state, prior

radiation therapyradiation therapy

3) Use topical therapy for initial 3) Use topical therapy for initial managementmanagement

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4) The choice of topical agent should be 4) The choice of topical agent should be ) p g) p gbased on:based on:

EfficacyEfficacyLow incidents of adverse eventsLow incidents of adverse events

Likelihood of adherenceLikelihood of adherenceCostCost

5) Clinicians should inform pts how to5) Clinicians should inform pts how to5) Clinicians should inform pts how to 5) Clinicians should inform pts how to administer the dropsadminister the drops


6) When the TM is nonintact, a non6) When the TM is nonintact, a non--6) When the TM is nonintact, a non6) When the TM is nonintact, a nonototoxic topical preparation should be ototoxic topical preparation should be

prescribedprescribed

7) If the patient fails to respond within 7) If the patient fails to respond within 48 to 72hrs the clinician should reassess48 to 72hrs the clinician should reassess48 to 72hrs, the clinician should reassess 48 to 72hrs, the clinician should reassess

the ptthe pt..

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Pay for performancePay for performance

Assess for pain at every visitAssess for pain at every visit Assess for pain at every visitAssess for pain at every visit

Prescribe a topicalPrescribe a topical

Do Do notnot prescribe a systemicprescribe a systemic

Canal CholesteatomaCanal Cholesteatoma

UnilateralUnilateral Multiple etiologiesMultiple etiologies UnilateralUnilateral

Not associated with Not associated with systemic diseasesystemic disease

OlderOlder

Rx: medical or Rx: medical or i li l

Multiple etiologiesMultiple etiologies congenitalcongenital

Post traumaticPost traumatic

Post obstructivePost obstructive

Post inflammatoryPost inflammatory

SpontaneousSpontaneoussurgicalsurgical SpontaneousSpontaneous

IatrogenicIatrogenic

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Keratosis ObturansKeratosis Obturans BilateralBilateral SymptomsSymptoms

Associated w Associated w sinusitis & sinusitis & bronchiectasisbronchiectasis

Rx: regular office Rx: regular office debridementdebridement

CHLCHL

Otorrhea rareOtorrhea rare

Pain Pain

1st and 2nd decades1st and 2nd decades

Keratosis CholesteatomaKeratosis Cholesteatoma

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ExostosisExostosis Suture linesSuture lines

17.5 C canal 17.5 C canal erythemaerythema

73% surfers73% surfers

Lateral to isthmusLateral to isthmus

OsteomaOsteoma

True neoplasmTrue neoplasm True neoplasmTrue neoplasm

SingleSingle

UnilateralUnilateral

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Exostosis OsteomaExostosis Osteoma ReactiveReactive NeoplasticNeoplastic ReactiveReactive

Non occlusiveNon occlusive

BilateralBilateral

MultipleMultiple

Sessile Sessile

NeoplasticNeoplastic

OcclusiveOcclusive

UnilateralUnilateral

SingleSingle

PeduculatedPeduculated

Lamellar boneLamellar bone Trabecular boneTrabecular bone

Exostosis OsteomaExostosis Osteoma

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Surgical TechniqueSurgical Technique

Skin flapsSkin flaps Skin flapsSkin flaps

ChiselChisel

DrillDrill

Facial Nerve!Facial Nerve! 14% Of FN 14% Of FN

l il iparalysis paralysis (Green)(Green)

Monitor?Monitor?

Granular MyringitisGranular Myringitis

DefinitionDefinitionDeDe –– epithelializationepithelializationDe De epithelialization epithelialization

of the tympanic of the tympanic membranemembrane

Granulation tissueGranulation tissueNormal middle earNormal middle ear

EtiologyEtiology Trauma, InfectionTrauma, Infection au a, ect oau a, ect o Impaired migration Impaired migration

provokes infection and provokes infection and induces trauma in the induces trauma in the lamina proprialamina propria

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Granular myringitisGranular myringitis

SymptomsSymptomsy py p Otorrhea (most common), aural fullness, subjective Otorrhea (most common), aural fullness, subjective

hearing loss, otalgia, tinnitus, aural pruritus.hearing loss, otalgia, tinnitus, aural pruritus. Physical examPhysical exam

Focal versus diffuseFocal versus diffuse Ulceration versus polypoid massUlceration versus polypoid mass Purulent discharge versus crustingPurulent discharge versus crusting

PerforationPerforation PerforationPerforation May occur as a result of diseaseMay occur as a result of disease Disease may occur in the setting of a prior Disease may occur in the setting of a prior

perforationperforation

Granular myringitisGranular myringitis Grade IGrade I

Focal disease of tympanic Focal disease of tympanic membrane +/membrane +/ ear canal skinear canal skinmembrane +/membrane +/-- ear canal skinear canal skin

Shallow ulceration +/Shallow ulceration +/--crustingcrusting

Grade IIGrade II Focal polypoid granulationFocal polypoid granulation Purulent possible foul Purulent possible foul

smelling otorrheasmelling otorrhea Grade IIIGrade III

Diffuse tympanic membraneDiffuse tympanic membrane Diffuse tympanic membrane Diffuse tympanic membrane involvementinvolvement

Grade IVGrade IV Diffuse involvement with Diffuse involvement with

granulation tissue including granulation tissue including canalcanal

Wolf M, Primov-Fever A, Barshack I, Polack-Charcon S, Kronenberg J. Granular Myringitis: Incidence and Clinical Characteristics. Otology & Neurotology 2006;27:1094-7. Blevins: Otol & Neurotol 2001 El-Seifi: AJO 2000

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Granular myringitisGranular myringitis TherapyTherapyTopicalTopical

Antibiotic combination steroid dropsAntibiotic combination steroid drops

PowdersPowders

Caustic solutions (Phenol, Trichloroacetic acid, Caustic solutions (Phenol, Trichloroacetic acid, Chromic acid.Chromic acid.

T l t +/T l t +/ ki ftki ftTympanoplasty +/Tympanoplasty +/-- skin graftskin graft

Laser therapy (CO2)Laser therapy (CO2)60% total resolution, 32% partial resolution at 3 months60% total resolution, 32% partial resolution at 3 months

Cheng Y, Shiao A. Intractable Chronic Myringitis Treated with Carbon Dioxide Laser Microsurgery. Archives of Otolaryngologg – Head and Neck Surgery 2008;134:152 - 156.

Granular myringitisGranular myringitis

ResultsResults ResultsResultsA dilute vinegar A dilute vinegar

solution has been solution has been shown to more shown to more effective than effective than topical antibioticstopical antibiotics

I f tI f t In refractory cases In refractory cases surgical excision surgical excision may reduce may reduce recurrence.recurrence.

Neilson L, Hussain S. Management of granular myringitis: A systematic review. The Journal of Laryngology & Otology 2008;122: 3-10.

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Malignant otitis externaMalignant otitis externa

PresentationPresentationi ii i Severe, unremitting Severe, unremitting

otalgia (worse at night), otalgia (worse at night), fullness, otorrhea, fullness, otorrhea, hearing loss, headache, hearing loss, headache, trismus, TMJ paintrismus, TMJ pain

ExamExam Granulation and Granulation and

exposed bone at BC exposed bone at BC junctionjunction

Facial nerve (25%) Facial nerve (25%) ( )( )most commonly most commonly affected cranial nerve, affected cranial nerve, followed by jugular followed by jugular foramen.foramen.

43% will present with 43% will present with cranial nerve cranial nerve involvementinvolvement

Moffat Axon Laryngoscope 2007


Risk factorsRisk factors Risk factorsRisk factorsDiabetes mellitus 65% or as high as 90 to Diabetes mellitus 65% or as high as 90 to

100% of patients (Franco100% of patients (Franco--vidal O&N vidal O&N 2007)2007)

HIV/AIDSHIV/AIDS

ChemotherapyChemotherapy

Leukemia/lymphomaLeukemia/lymphoma

SplenectomySplenectomy

TransplantTransplant

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Malignant Otitis externaMalignant Otitis externa

HIVHIV HIVHIVPatients are youngerPatients are younger

Suspect in patients with otitis externa Suspect in patients with otitis externa which does not improvewhich does not improve

May not to have granulation tissue in May not to have granulation tissue in EACEAC

Fungal infections more commonFungal infections more common

Pseudomonas when CD4 is less than 100 Pseudomonas when CD4 is less than 100

Aspergillus when CD4 less than 50 Aspergillus when CD4 less than 50


Differential diagnosisDifferential diagnosis Differential diagnosisDifferential diagnosisCarcinoma of EACCarcinoma of EAC

Biopsy granulation if persistentBiopsy granulation if persistent

Granulomatous diseasesGranulomatous diseases

PagetPaget’’s diseases disease

Nasopharynx malignanciesNasopharynx malignancies

Clival lesionsClival lesions

Fibrous dysplasiaFibrous dysplasia

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PathophysiologyPathophysiology elderly moreelderly more Pathophysiology Pathophysiology –– elderly more elderly more susceptiblesusceptibleEndarteritis, microangiopathy, small Endarteritis, microangiopathy, small

vessel obliterationvessel obliteration

Pseudomonas can invade vessel wall Pseudomonas can invade vessel wall li i d h b ili i d h b icause vasculitis and thrombosiscause vasculitis and thrombosis

Poor chemotaxis and phagocytosisPoor chemotaxis and phagocytosis

Higher cerumen pH in diabetes and malesHigher cerumen pH in diabetes and males

Infection spreads through Haversion Infection spreads through Haversion system not air cells.system not air cells.

MOE stagingMOE staging

STAGE ISTAGE I: infection of canal and: infection of canal and STAGE ISTAGE I: infection of canal and : infection of canal and contiguous soft tissue w/wo CN VII contiguous soft tissue w/wo CN VII involvementinvolvement

STAGE IISTAGE II: Extension to include : Extension to include osteitis of skull base and multiple osteitis of skull base and multiple

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cranial nervescranial nerves

STAGE IIISTAGE III: Intracranial : Intracranial complicationscomplications

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DiagnosisDiagnosisCTCTCT CT

Sensitive for bone erosion Sensitive for bone erosion

Permanent.Permanent.

No ideal for f/u No ideal for f/u

MRI MRI Sh d d i lSh d d i lShows marrow and dura involvementShows marrow and dura involvement

Enhancement may be prolonged Enhancement may be prolonged –– not ideal not ideal for f/ufor f/u

Poor at showing bone erosion Poor at showing bone erosion

Not an ideal initial study.Not an ideal initial study.


DiagnosisDiagnosis Technetium Tc 99m Technetium Tc 99m

methylene diphosphonate methylene diphosphonate (MDP) (MDP) Positive in nearly Positive in nearly

100% of MOE100% of MOE Concentrates in areas Concentrates in areas

of osteoblastic activityof osteoblastic activity Better for initial Better for initial

diagnosisdiagnosis Increase sensitivity by Increase sensitivity by y yy y

identifying increase identifying increase uptake 4 to 24 hours uptake 4 to 24 hours after injection. after injection.

Positive in cancersPositive in cancers Remains positiveRemains positive

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DiagnosisDiagnosis DiagnosisDiagnosisGallium Ga 67Gallium Ga 67

Concentrates in areas with active inflammationConcentrates in areas with active inflammation

Attaches to lactoferrin (large quantities in leukocytes)Attaches to lactoferrin (large quantities in leukocytes)

Binds directly to bacteria and transferrinBinds directly to bacteria and transferrin

Resolves with resolution of infectionResolves with resolution of infection

Can repeat every 4 weeksCan repeat every 4 weeks

Follow with Gallium 67 and ESRFollow with Gallium 67 and ESR Stop therapy when these both normalizeStop therapy when these both normalize

Can recur up to year laterCan recur up to year later

Malignant Otitis ExternaMalignant Otitis Externa

Diagnostic work upDiagnostic work up Diagnostic work upDiagnostic work upBiopsy granulation tissueBiopsy granulation tissue

Culture (aerobe, anaerobe, fungal and Culture (aerobe, anaerobe, fungal and sensitivities)sensitivities) Initiate empiric therapy while awaiting Initiate empiric therapy while awaiting

culturesculturesculturescultures

Silver stain to ID fungal elementsSilver stain to ID fungal elements

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Bacterial pathogensBacterial pathogens Bacterial pathogensBacterial pathogensPseudomonas aeruginosaPseudomonas aeruginosa most commonmost common

33% resistance to Cipro in one series (Bernholz & 33% resistance to Cipro in one series (Bernholz & Harell Lscope 2002Harell Lscope 2002

Other organisms: Other organisms: Staphylococcus aureus, Staphylococcus aureus, S epidermidis, Proteus mirabilis, S epidermidis, Proteus mirabilis, p , ,p , ,Klebsiella oxytoca, P cepaciaKlebsiella oxytoca, P cepacia

Aspergillus fumigatusAspergillus fumigatus is the most is the most common fungal agentcommon fungal agent Unresponsive to antibioticsUnresponsive to antibiotics

Negative culturesNegative cultures


Oral versus intravenous antibioticsOral versus intravenous antibioticsO ve sus ve ous b o csO ve sus ve ous b o cs Single versus double coverageSingle versus double coverage Duration of treatment 6 to 8 weeksDuration of treatment 6 to 8 weeks Oral Cipro 750 mg BID is acceptableOral Cipro 750 mg BID is acceptable May add RifampinMay add Rifampin Can use antipseudomonal PCN with concurrent Can use antipseudomonal PCN with concurrent

aminoglycoside in resistant and complicated casesaminoglycoside in resistant and complicated casesaminoglycoside in resistant and complicated casesaminoglycoside in resistant and complicated cases Culture negative (Djalilian HR O&N 2006)Culture negative (Djalilian HR O&N 2006)

Ceftazidime IV + Oral Cipro 750mg BID, topical Ceftazidime IV + Oral Cipro 750mg BID, topical aminoglycoside steroid dropsaminoglycoside steroid drops

Use aztreonam for PCN allergic patientsUse aztreonam for PCN allergic patients

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Amphotericin B for fungal MOEAmphotericin B for fungal MOE Amphotericin B for fungal MOEAmphotericin B for fungal MOELiposomal Amphotericin B is less toxic Liposomal Amphotericin B is less toxic

with equal efficacy. with equal efficacy.

Oral itraconazole after amphotericin Oral itraconazole after amphotericin has also been used successfully.has also been used successfully.


Is there a role for hyperbaric oxygen?Is there a role for hyperbaric oxygen?

Increases the partial pressure of oxygen Increases the partial pressure of oxygen improving hypoxia and allowing greater improving hypoxia and allowing greater oxidative killing of bacteriaoxidative killing of bacteria

One series 7 of 8 patients recoveredOne series 7 of 8 patients recovered

No evidence to support its use by Cochrane No evidence to support its use by Cochrane reviewreview

Limited role for surgeryLimited role for surgeryg yg y

Debridement of bone sequestrum and Debridement of bone sequestrum and granulation granulation

Biopsy Biopsy

Duration of treatment is typically 6 weekDuration of treatment is typically 6 weekss

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Malignant Otitis externaMalignant Otitis externa PrognosisPrognosis

li d dli d dMortality decreased 50% to 0 to 15%.Mortality decreased 50% to 0 to 15%.

Aspergillus, dural involvement are poor prognostic Aspergillus, dural involvement are poor prognostic factorsfactors

Facial nerve palsy can recover but incompleteFacial nerve palsy can recover but incomplete

Lower cranial nerve palsies can completely Lower cranial nerve palsies can completely recover.recover.

MOE oral quinolonesMOE oral quinolones

GiamarellouGiamarellou GiamarellouGiamarellou159 patients159 patients

Ciprofloxacin 88/101Ciprofloxacin 88/101

Ofloxacin 38/46 (5 resistant)Ofloxacin 38/46 (5 resistant)

58

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Chronic External OtitisChronic External OtitisChronic External OtitisChronic External Otitis

A low grade diffuse infection of theA low grade diffuse infection of the A low grade, diffuse infection of the A low grade, diffuse infection of the external canal that persist for months external canal that persist for months or yearsor years

It is characterized clinically by It is characterized clinically by pruritits, scanty otorrhea and pruritits, scanty otorrhea and

59

progressive narrowing of the lumen of progressive narrowing of the lumen of the EAC. the EAC.

Duration exceeds 4 weeks or more Duration exceeds 4 weeks or more than 4 infections in one year.than 4 infections in one year.

PathologyPathologyPathologyPathology Mild to moderate Mild to moderate

ddedemaedema

Chronic Chronic inflammatory cell inflammatory cell infiltrateinfiltrateOften focalOften focal

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Often focalOften focal

Microabscess Microabscess formationformation

Areas of calcificationAreas of calcification

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PathologyPathologyPathologyPathology Progressive Progressive

b ith li l fib ib ith li l fib isubepithelial fibrosis subepithelial fibrosis leading to stenosisleading to stenosisPost inflammatory Post inflammatory

medial canal fibrosismedial canal fibrosis

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PathologyPathologyPathologyPathology

62

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Clinical PresentationClinical PresentationClinical PresentationClinical Presentation Hearing loss is a Hearing loss is a

more commonmore commonmore common more common presenting presenting symptom than symptom than otorrheaotorrhea

Females 2:1Females 2:1 Exacerbated by Exacerbated by

hearing aidshearing aids

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Often starts in Often starts in anterior sulcus anterior sulcus

Bilateral in 50%Bilateral in 50%

Physical examinationPhysical examination

Absent cerumenAbsent cerumen Absent cerumenAbsent cerumen Raw epithelial Raw epithelial

surfacesurface——erythemaerythema ElephantiasisElephantiasis Scant, milky Scant, milky

otorrheaotorrhea

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ShinnyShinny Narrowing of the Narrowing of the

lumenlumen

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InfectiousInfectious

BacterialBacterial BacterialBacterialGram negative, especially Pseudomonas Gram negative, especially Pseudomonas StaphyloccusStaphyloccus

MycoticMycoticNot common pathogens in AOE but role Not common pathogens in AOE but role

in COE unclearin COE unclear probably greaterprobably greater

65

in COE unclearin COE unclear------probably greaterprobably greaterAspergillus & CandidaAspergillus & CandidaSlow growing fungi may be missedSlow growing fungi may be missed““IdId”” reactionsreactions

DermatologicalDermatological

Seborrheic dermatitisSeborrheic dermatitis Seborrheic dermatitisSeborrheic dermatitis fam history, scalp (fam history, scalp (““dandruffdandruff””), ),

flexures (retroflexures (retro--auricular) auricular)

PsoriasisPsoriasisOccasionally is isolated to earsOccasionally is isolated to ears

66

May develop from seborrheaMay develop from seborrhea

NeurodermatitisNeurodermatitis

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SensitizationSensitization

1st case1st case of contact allergy of contact allergy to Neomycin was reportedto Neomycin was reportedto Neomycin was reported to Neomycin was reported in l952 by Baer and in l952 by Baer and Ludwig in a pt with Ludwig in a pt with chronic OE!chronic OE!

Cross reactivityCross reactivitybetween Neomycin and between Neomycin and other Aminoglycosides is other Aminoglycosides is common. Cf tobra in the common. Cf tobra in the NetherlandsNetherlands

The reaction time of the The reaction time of the aminoglycosides in patch aminoglycosides in patch testing almost always testing almost always exceeds 3 days andexceeds 3 days and

67

exceeds 3 days and exceeds 3 days and often takes 7 daysoften takes 7 days

The routine use of The routine use of Neomycin is not Neomycin is not recommended because of recommended because of the high risk of the high risk of sensitizationsensitization

HypersensitivityHypersensitivity

WARNING:WARNING: THETHE WARNING:WARNING: THE THE MANIFESTATION OF MANIFESTATION OF SENSITIZATION TO SENSITIZATION TO

NEOMYCIN IS NEOMYCIN IS USUALLY A USUALLY A LOW LOW

GRADEGRADE REDDENING REDDENING WITH SWELLING, DRY WITH SWELLING, DRY

SCALING ANDSCALING AND

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SCALING AND SCALING AND ITCHING; ITCHING; IT MAY IT MAY

SIMPLY MANIFEST AS SIMPLY MANIFEST AS FAILURE TOFAILURE TO HEALHEAL

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MixedMixed

The majority of cases of COE areThe majority of cases of COE are The majority of cases of COE are The majority of cases of COE are probably in this categoryprobably in this category

69

TreatmentTreatment

MedicalMedical MedicalMedicalEarly stage of disease. Early stage of disease. IdeallyIdeally will will

prevent stenosisprevent stenosis

May only serve to slow progressionMay only serve to slow progression——no no long term outcome datalong term outcome data

70

SurgicalSurgicalLate stage of disease. Late stage of disease.

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Medical TherapyMedical Therapy SteroidsSteroids: drops, creams, : drops, creams,

injections?injections?injections?injections?

Single agents. Single agents. ophthalmic drops or ophthalmic drops or dermatologic creamsdermatologic creams

Combination agentsCombination agents

Topical TacrolimusTopical Tacrolimus

Caffer P, et al. Tacrolimus: A New Option in Therapy-Resistant Chronic Otitis Externa. Laryngoscope 2007;117:1046 – 52. 71

More effective in dry More effective in dry rather than wet casesrather than wet cases

Complete resolution in Complete resolution in 46% patients.46% patients.

Medical TherapyMedical Therapy

AntibioticsAntibiotics AntibioticsAntibioticsUse sparinglyUse sparinglyQuinolone drops Quinolone drops PowdersPowders----last last

longer & can longer & can include multiple include multiple

72

ppagentsagents

CultureCulture

““No TouchNo Touch”” aural aural toilettoilet

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Surgical TherapySurgical Therapy

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Local flapsLocal flaps

PrePre conchal post auricularconchal post auricular PrePre--conchal, post auricular conchal, post auricular Tendency to contract may help pull canal Tendency to contract may help pull canal

openopen

Decreased scarring because Decreased scarring because vascularityvascularity

Hard to get enough length Hard to get enough length

74

BulkyBulky

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FTSG vs. STSGFTSG vs. STSG Greater resistance Greater resistance

to traumato trauma Most commonly Most commonly ddto traumato trauma

Glandular elements Glandular elements provide lubricationprovide lubrication

Less likely to Less likely to contractcontract

usedused

Easiest to obtainEasiest to obtain

Less reLess re--stenosis?stenosis?

75

contractcontract

Successful operationsSuccessful operations

Completely remove cicatrixCompletely remove cicatrix Completely remove cicatrixCompletely remove cicatrix

Include a canalplastyInclude a canalplasty

Resurface the bony canal with skin Resurface the bony canal with skin

76

Roland 39

Surgical resultsSurgical results ≈ 80% patent canal but ≈ 80% patent canal but

l tl trecurrences occur late recurrences occur late earliest @ 3yrs in earliest @ 3yrs in

SlatterySlattery’’s seriess series

Hearing improvements Hearing improvements range from 10dB to range from 10dB to

77

gg50dB 50dB 61% with closure of the 61% with closure of the

airair--bone ABG to 20 dB bone ABG to 20 dB (Beckers (Beckers ---- 53 pts)53 pts)

Documents

Diseases of the EAC - Alexorlalexorl.edu.eg/alexorlfiles/alexorl2013-presentations/018001.pdf · Roland 2 Excess cerumen Adults 3Adults 3-10%10 % 5 di N50005 studies N=5000 Children